A case of ceftriaxone-induced immune haemolytic anaemia in an ambulatory care setting

Background

Drug-induced immune haemolytic anaemia (DIIHA) is a rare adverse effect which varies between mild to fatal (Garratty, 2010). One of the most common class of drugs reported to cause severe DIIHA are the second and third generation cephalosporins (e.g. ceftriaxone) (Garratty, 2010, Hill et al., 2017).

We report an event of severe, life-threatening DIIHA caused by ceftriaxone administered in an ambulatory setting to a patient via Outpatient Parenteral Antimicrobial Therapy (OPAT) service and our subsequent management of the adverse reaction.

Case report

A 60-year old male was referred to the OPAT service for radiologically-confirmed osteomyelitis. He was commenced on ceftriaxone 4 g daily intravenous infusions in the ambulatory care unit. Shortly after receiving the ninth dose, he became acutely pale, tachycardic, tachypnoeic, and hypotensive with multiple witnessed syncopal episodes inside the unit. Haemoglobin level fell to <30 g/L on blood gas and on formal laboratory analysis (Abbott® Alinity) 39 g/L (from baseline of 97 g/L). No obvious source of bleeding was identified which suggested an acute haemolytic process.

Management included high-dose corticosteroids and a single dose of intravenous immunoglobulin. Ceftriaxone was immediately discontinued and a beta-lactam free regimen was commenced. Haemoglobin level improved within 24 h with a gradual return to baseline within seven days.

Conclusions

Our case highlights the need for ambulatory care and OPAT teams to be aware of this rare, idiosyncratic adverse reaction which may occur in otherwise clinically stable patients. We advocate weekly haematological monitoring in OPAT patients.